2017-05-15T10:51:18-05:00 2016-09-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2015-10-01 390799566 Tomah Memorial Hospital TOMA 6083722181 321 Butts Avenue Tomah WI 54660 Joseph Zeps Chief Financial Officer 6083722181 2017-05-12 1 Kim Hunwardsen CPA P00484560 6122536500 2017-05-12 2015 2021-01-29 14:40:06Z Philip J Stuart 321 Butts Avenue Tomah WI 54660 55823024 0 X www.tomahhospital.org X 1948 WI To promote and provide quality health care to patients in a hospital setting 10 10 371 45 0 0 168838 105888 47063633 48780483 1229776 366064 -2056 18874 48460191 49271309 0 0 0 0 21416317 22945034 0 0 0 20849253 22404472 42265570 45349506 6194621 3921803 57907603 62359385 9688435 8366956 48219168 53992429 X The mission of Tomah Memorial Hospital, Inc. is to promote and provide quality health care based on customer needs and expectations. In fulfillment of its mission, Tomah Memorial Hospital is committed to view its customers and employees through a holistic approach without consideration to economic status, gender, ethnic origin or personal limitations. 0 0 33568179 46283530 Tomah Memorial Hospital has provided for the health and well-being of the residents of Tomah and the surrounding communities for nearly sixty five years. The Hospital provides a broad spectrum of health and wellness services to the community, including general medical/surgical and swing bed inpatient care, diagnostic laboratory and radiology services, general and specialty surgical services, 24 hour emergency care services, obstetric services, rehabilitative services, occupational health and wellness programs, and a community outreach program. Key volume indicators for the fiscal year ended September 30, 2016 are as follows:* 1,286 inpatient discharges* 3,539 inpatient days* 16,767 emergency room and urgent care visits* 1,669 surgical and endoscopic procedures* 13,560 radiology procedures (including CT and MRI)* 69,452 laboratory tests* 34,198 rehabilitative services proceduresIn furtherance of its charitable mission, the Hospital provided approximately $1,104,500 of free and discounted care to area residents (cost of care approximately $569,500), and wrote off $1.80 million of uncollectible accounts (cost equal to approximately $930,000). Additionally, based on its most recently completed community benefits survey, the Hospital incurred approximately $2.08 million in net losses related to providing care for individuals with health insurance provided by either the Medicaid program or other governmental insurance programs. The Hospital subsidizes several programs that are deemed vital services for the community, including in-home hospice and palliative care services, a hospice residence, a walk-in clinic located in the rural community of Warrens, WI, and a dedicated community outreach department that provides health and wellness services to area employers and the Tomah community. Subsidies for these programs for fiscal 2016 approximated $2.51 million. Additional details regarding the hospice program and the Warrens Walk-In Clinic can be found below. In addition to providing high quality healthcare services, the Hospital encourages employees to become actively involved in community organizations and projects that provide other benefits to local communities. The Hospital provides many free services to the community, including health and wellness presentations to area school children, CPR and AED training to various organizations, wellness fairs devoted to women and senior citizens, and meeting space to various non-profit and civic organizations. 3603878 1860622 The Hospital provides in-home, inpatient, and residential hospice care to residents of Tomah and the surrounding communities. Residential care is provided via the operation of an eight bed hospice house located off campus. Despite subsidizing the financial losses incurred by the program, the services are deemed vital to the community and represent a necessary component of patient care. For the year ended September 30, 2016, the Hospice program experienced 9,974 program days and 1,132 hospice residence days. 891999 636331 The Hospital began operating an off-site walk-in care clinic several years ago to better serve the needs of the residents of Warrens, Wisconsin. For the fiscal year ended September 30, 2016, the clinic accommodated 4,375 patient visits. The clinic provides residents with a close-to-home, low-cost option for healthcare services (including basic laboratory tests and x-ray capabilities) related to minor injuries and illnesses, and all services provided are supported by the Hospital's Emergency Department. Despite incurring a negative gross contribution margin during 2016, the Hospital's Board of Directors believes the clinic is an important asset to the residents of Warrens and remains committed to supporting it until it achieves a sustainable level of financial performance. 38064056 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 14 0 1 371 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Joseph Zeps 6083740307 321 Butts Avenue Tomah WI 54660 Wes Revels Chair 1.00 0.00 X X 0 0 0 Cynthia Erdman Vice Chair 1.00 0.00 X X 0 0 0 James Quartemont Secretary 1.00 0.00 X X 0 0 0 Paul Potter Treasurer 1.00 0.00 X X 0 0 0 Michael Saunders MD Director 1.00 0.00 X 0 0 0 Jill Boulden MD President of Medical Staff 1.00 0.00 X 0 0 0 Kurt Olson Director 1.00 0.00 X 0 0 0 Terrie Gaarder Director 1.00 0.00 X 0 0 0 Patty Clark Director 1.00 0.00 X 0 0 0 Tom Bramwell Director 1.00 0.00 X 0 0 0 Philip J Stuart Administrator 40.00 0.00 X 0 0 0 Joseph Zeps Chief Financial Officer 40.00 0.00 X 148289 0 36511 Lily Liu MD Geriatric & Family Medicine 40.00 0.00 X 306250 0 7385 Darla Wilson Director of Pharmacy 40.00 0.00 X 173450 0 18209 Todd Chapman Pharmacist 40.00 0.00 X 157941 0 6309 Gerald Fushianes PA-C Physician Assistant 40.00 0.00 X 151917 0 36759 Laura J Miller FNP Nurse Practitioner 40.00 0.00 X 134369 0 16666 1072216 0 121839 20 0 1 0 Gundersen Lutheran Health Systems 1900 South Ave LaCrosse WI 54601 Contracted ER physicians/dietician 1677886 Tomah Orthopedics 321 Butts Avenue Tomah WI 54660 Contracted orthopedic surgeon services 1212021 Mayo Clinic Health System 201 W Center St Rochester MN 55902 Contracted hospitalist/pathology service 1035131 Medical X-Ray Consultants 900 W Clairemont Avenue Eau Claire WI 54701 Contracted radiologist services 891932 Rural Wisconsin Health Cooperative Infor 880 Independence Lane Sauk City WI 53583 HIS software licensing/service/support/h 666021 16 10083 18609 77196 105888 Patient service revenue 622110 48479454 48479454 301029 301029 48780483 978742 978742 71749 52875 18874 18874 18874 5886162 6498840 -612678 -612678 -612678 49271309 48780483 0 384938 X 191673 191673 41094 41094 17615405 15087333 2528072 509170 437590 71580 3272738 2807691 465047 1314954 1125541 189413 571136 571136 38869 38869 55446 55446 8400689 7220283 1180406 216107 216107 1989567 1117970 871597 412903 401910 10993 150349 120946 29403 119932 92455 27477 239053 239053 2571947 2571947 123758 123758 Medical supplies 4185069 4185069 Bad debt expense 1803040 1803040 Repairs and Maintenance 903091 678199 224892 623516 133935 489581 45349506 38064056 7285450 0 6699801 7439130 5849705 6440054 607411 710767 159023 985480 37609732 23655134 13925705 13954598 30114145 32229364 8816 8816 542997 591176 57907603 62359385 2787685 2247516 6509678 6059440 261072 0 130000 60000 9688435 8366956 X 47263033 52940455 3685 3685 952450 1048289 48219168 53992429 57907603 62359385 X 3921803 1796574 54884 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 952450 34130 72113 10404 1048289 869600 102541 -9919 9772 952450 756737 45853 78568 11558 869600 655732 55282 56609 10886 756737 539204 39504 86657 9633 655732 0.00000 1.00000 0.00000 0 0 1706459 1706459 22151071 14437021 7714050 13091391 8951941 4139450 660811 266172 394639 13954598 Estimated Third-Party Payor Settlements 60000 60000 X 49266359 1796574 -1803040 -6466 49272825 -1516 -1516 49271309 43599341 52875 52875 43546466 1803040 1803040 45349506 Part V, Line 4: Permanently restricted net assets are restricted to the Hospice endowment fund and the beneficial interest in a perpetual trust. The interest earned can be used for hospice expenditures. Part X, Line 2: Tomah Memorial Hospital and the Auxiliary are organized as a Wisconsin nonprofit corporations and have been recognized by the IRS as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). Tomah Memorial Hospital and the Auxiliary are annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, Tomah Memorial Hospital and the Auxiliary are subject to income tax on net income that is derived from business activities that are unrelated to their exempt purpose. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and, as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense, if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts in revenue for financial statements -1,803,040. Part XI, Line 4b - Other Adjustments: Temporarily restricted interest income included in fund balance 10,404. Rental expenses recorded in expenses for financial statements -52,875. Permanently restricted interest income included in fund balance 6,825. Permanently restricted contributions included in fund balance 34,130. Part XII, Line 2d - Other Adjustments: Rental expenses recorded in expenses for Financial Statements 52,875. Part XII, Line 4b - Other Adjustments: Provision for bad debts in revenue for financial statements 1,803,040. 1 1 X 1 X 1 X 1 1 1 0 1 1 1044 578000 578000 0.01330 1 8524 14836196 12945782 1890414 0.04340 1 2299 5328877 5135861 193016 0.00440 2 11867 20743073 18081643 2661430 0.06110 512910 295219 217691 0.00500 15 38469 38469 0.00090 4785295 2496953 2288342 0.05250 15 5336674 2792172 2544502 0.05840 2 11882 26079747 20873815 5205932 0.11950 0 1803040 274062 9389282 9433706 -44424 X 1 1 1 1 Tomah Memorial Hospital 321 Butts Avenue Tomah WI 54660 www.tomahhospital.org 1023 X X X Warrens Walk-In Clinic - provider based Tomah Memorial Hospital 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X www.tomahhospital.org X 1 15 1 http://www.tomahhospital.org/content/detail.cfm?pageid=205 0 0 1 X 100.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X www.tomahhospital.org X www.tomahhospital.org X www.tomahhospital.org X X X X X 1 X 0 X X X 1 X 0 0 Tomah Memorial Hospital Part V, Section B, Line 5: The Hospital participated in a collaboration of several area non-profit healthcare providers and various community organizations (e.g. local United Way organizations, county health departments, etc.) to conduct a comprehensive community health needs assessment of Tomah, WI, and the surrounding communities. Input for the assessment was solicited via random household surveys and focus group discussions with community members. Leadership for the assessment was provided by representatives from Gundersen Health System and the Great Rivers United Way, with additional representation from healthcare facilities in Hillsboro, Sparta, LaCrosse, Viroqua, and Tomah, WI, as well as county health departments located in Vernon, LaCrosse, Monroe, Trempeleau, and Houston Counties. Tomah Memorial Hospital Part V, Section B, Line 6a: Gundersen Health SystemGundersen St. Joseph's Hospital and ClinicsGundersen Tri County Hospital and ClinicsMayo Clinic Health System - LaCrosse and SpartaVernon Memorial Healthcare Tomah Memorial Hospital Part V, Section B, Line 11: The Community Health Needs Assessment completed by June 30, 2016 included the following significant needs.Adverse Childhood Experiences (ACEs)Current Action1. Tomah Memorial and the Monroe County CHIP Mental Health Workgroup received a grant to host a presentation by Gundersen National Child Protection Training Center. This training focused on Adverse Childhood Experiences and increasing the community's collective ability to support individuals who have experienced traumatic events. Healthcare personal, teachers, social workers, and public health workers were present at the training. 2. The Hospital is the co-chair of the Monroe County CHIP Mental Health Committee and the topic of ACEs is addressed throughout the year at monthly meetings. Workforce ReadinessCurrent Action1. Tomah Memorial Hospital has partnered with the Tomah High School to support the Healthcare Careers Class and the Certified Nursing Assistant (CNA) Certification Class.2. Tomah Memorial donates to the American Heart Association Healthcare Provider CPR/AED and First Aid Certification Courses to the Healthcare Careers and the CNA classes. 3. Hospital Tours - to show students the diversity of the healthcare field 4. CNA Clinical Rotation5. HIPAA Training6. Junior Achievement Classes7. Reality Check at Tomah High SchoolFuture ActionThe hospital is working with the Tomah Area School district to continue developing the opportunities and trainings available for the CNA and Healthcare Careers classes. Youth Resilience Current Action1. The hospital has a presence on the Tomah Boys and Girls Club Executive Board and is currently working on programming to increase students' abilities to manage stress and prepare for adulthood.2. Tomah Memorial has a presence on the Tomah Boys and Girls Club Education and Resource Committees, finding volunteers and educational presentations to enrich students in the Tomah area. Future ActionThe hospital is working with the Boys and Girls Club to host a "Teen Night" centered on health education and job readiness. This night would be a similar event to the current Hospital Men's Night and Women's Night, just geared toward a younger population.Alcohol Use and Illegal Drug UseCurrent Action1. Reasonable Suspicion Training This presentation covers the physical, mental, and emotional effects of drug and alcohol use (both short and long term) with information specific to Monroe county. Participants are shown what signs to look for in drug abuse and how to help someone who is struggling with substance abuse. 2. Cancer Prevention PresentationsOne of the ways to reduce your risk of developing cancer is to limit the amount of alcohol consumed. These presentations encourage healthy alcohol consumption and cover some of the physical and emotional effects of long term alcohol abuse.3. Attendance of the "Wake-Up Call" RoomMonroe County Safe Communities Coalition sponsored an event where interested parties were shown how a child can hide drug or alcohol use within their room. 4. Thiesen's GrantTomah Memorial Hospital, Monroe County Safe Communities Coalition, and the Monroe County Health Department have received a grant to provide presentations on locking up and properly disposing of medication to the public. Personal medication lock boxes will be purchased and given to many of the local daycares in Monroe County who do not have a place to safely lock away medication. The grant will also help purchase a larger medication drop box for the Sparta Police Department to handle the large volume of medications dropped off at the department. Future ActionWe're currently working with the Monroe County Health Department, WHEEP Western Healthcare Coalition, and Couleecap, a non?profit organization that fights poverty and promotes self-sufficiency, economic development, and social justice, to host several presentations about the effects of drug & alcohol. The Lybert Family from Your Choice to Live, LLC will be sharing their story of how drug and alcohol use affected their family with High School and Middle Schools students in the Tomah, Cashton, and Sparta School Districts. A presentation from the entire Lybert family will also be held for Monroe County to address the drug and alcohol about issue. Mental HealthCurrent ActionThe hospital is a part of the Monroe County CHIP Mental Health Workgroup in order to discover how we can expand the mental health services available to Monroe County. The workgroup is currently focusing on youth in Monroe County.Tomah Memorial has partnered with the Rural Wisconsin Health Cooperative, St. Croix Regional Medical Center, and the Monroe County Health Department to provide 8 hours of psychiatric telehealth services per month to underserved clients within Monroe County. Future ActionIn 2017, we'll provide QPR Suicide Prevention Trainings to students in the Cashton and Tomah Area School Districts and to Emergency Department Staff at Tomah Memorial Hospital to better equip them to deal with people struggling with suicidal thoughts. The Monroe County CHIP Mental Health Committee will work to provide Mental Health First Aid Presentations to Monroe County High School health classes. ObesityCurrent Action1. Women and Men's Health Night and the Senior Health and Safety Expo2. Winnebago Wednesday - Tomah Memorial has an interactive booth every year where kids are shown different fun ways to stay active throughout the year. 3. Healthy Eating and Quick Cooking Presentations4. Heart Health Presentations5. Whitney's Healthcheck on Lynxx 24 network6. Label Reading Presentations7. Employee Wellness Committee8. Health Fair Participation9. Monthly Wellness Presenations10. Health Risk Assessments11. Impact Tomah Future ActionWe're in the process of fostering further relations with the Tomah Area School District to explore how the hospital can help promote exercise and a healthy lifestyle.ChildcareCurrent ActionsThe hospital currently offers a community babysitting class that equips children 11-15 years to handle the responsibility of caring for another child. The hospital offers water birth, prepared childbirth, breastfeeding, sibling, and infant CPR & car safety classes to increase the quality and safety of basic childcare. Tomah Memorial Hospital Part V, Section B, Line 16i: Brochures containing information about financial assistance are available to patients. The Hospital's website contains information regarding community care and financial assistance. Contact information regarding community care and financial assistance is included on billing statements. Summary and contact information is also included in the emergency room, waiting rooms, and business office. The Hospital employs a full-time, dedicated patient benefit specialist who works with uninsured and underinsured patients regarding community care applications and financial assistance. Tomah Memorial Hospital Part V, Section B, Line 22d: Tomah Memorial Hospital uses the Look Back Method to determine the maximum amounts charged to patients eligible for financial assistance. The aggregate discount percentage is computed based on the Hospital's most recent audit report, and is calculated by dividing total contractual adjustments by total patient service revenue. Total patient service revenue is comprised of all charges for all departments of the Hospital. Individual charges are reviewed annually for reasonableness, and charges are set based on the costs incurred to provide the service, industry benchmark data, and Medicare reimbursement levels. 1 1 - Hospice Touch Serenity House 330 Butts Avenue Tomah WI 54660 Hospice residence Part I, Line 6a: The Organization participates in the Wisconsin Hospital Association (WHA) Annual Community Benefit reporting process, which is released to the public via a written report distributed to member hospitals as well as the WHA's website. This reporting initiative attempts to quantify the amount of community benefits provided by the Hospital, and includes figures related to community care write-offs, bad debt write-offs, Medicare and Medicaid shortfalls, and programs operated at a loss.The Organization also prepares a quarterly newsletter that is distributed to the public via a mass-mailing. The quarterly newsletter is intended to provide the communities the Hospital serves information regarding Hospital operations, financial results, and programs/initiatives intended to fulfill the Hospital's commitment to community. The newsletter also contains financial highlights from the WHA community benefit report. Current and prior editions of the newsletter are available on the Hospital's website. Part I, Line 7: The methodology for determining charity care and Medicaid/Tricare shortfalls at cost was as follows: a cost to charge ratio was computed using totals from the Hospital's audited financial statements; this ratio was applied to charity care charges, and gross Medicaid/Tricare revenue. Actual reimbursement received from Medicaid/Tricare was then compared to the estimated cost (computed by multiplying the CCR by gross charges) to determine the shortfall. All other items were based on actual program expenses. Also worth noting that the methodology used for charity care/Tricare/Medicaid is the same as the methodology used by the Wisconsin Hospital Association in compiling their annual community benefit report. Part I, Ln 7 Col(f): The amount of bad debt removed from total expenses to determine the percentage was $1,803,040. Part III, Line 2: Accounts are not written off to bad debt until all forms of payment have been applied to the account such as insurance, discounts, and contractual allowances, and the remaining balance is the personal portion due. A payment received on an account previously written off to bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy is determined by using the percentage of individuals living below the poverty level in Tomah, WI. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 8 of the attached audited financial statements. Part III, Line 8: Tomah Memorial Hospital follows the CHA guidelines in reporting community benefits and therefore any Medicare shortfall is excluded from our community benefit report. Providing services to Medicare patients is essential to these patients and the community and increases their access to healthcare services, which is a community benefit.Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by The Centers for Medicaid and Medicare services. Part III, Line 9b: Tomah Memorial Hospital attempts to screen all elective/scheduled patients prior to the receipt of service regarding community care eligibility, and works with patient financial services staff to identify emergent/unscheduled patients who may be eligible for community care (generally after receipt of service). Patients without insurance are offered a 15% discount. Patients that express an interest in community care assistance, are in the process of applying for community care assistance, or waiting on a determination of community care assistance will not have collection efforts imposed on their accounts. After a determination of community care assistance is made, any personal portion due by the patient will follow the same collection procedures as other patients. Part VI, Line 2: Tomah Memorial Hospital currently operates on a three-year strategic planning cycle. At the beginning of each cycle, a strategic planning retreat is held during which an analysis is conducted of the services the Hospital currently provides and areas of need that should be addressed by the Hospital. The retreat is open to all Hospital staff, Hospital Board Members, and members of the Hospital's medical staff. The Hospital's medical staff is comprised primarily of physicians employed by other area healthcare providers (e.g. Mayo, Gundersen Lutheran), and as such their input into the strategic planning process allows the Hospital to work collaboratively with other hospitals and health systems in assessing the needs of the community. The strategic planning process is facilitated by a representative of HealthTech Management Services, Inc. (contracted management organization), and the three year plan that is adopted by the Hospital's governance serves as a blueprint for ensuring the Hospital is addressing the needs of the community.In addition to the formal strategic planning process, the Hospital engages in ongoing discussions with various stakeholders (area businesses, physicians, patients, and community members) regarding the services offered at the Hospital, and Hospital leadership evaluates all suggestions offered for improving the many ways in which the Hospital serves its community.Finally, the Hospital participated in a collaborative community health needs assessment project with other area healthcare providers and county health departments. The final report and the Hospital's implementation plan are published on the Hospital's website at www.tomahhospital.org. Part VI, Line 3: Tomah Memorial Hospital makes available brochures containing information about financial assistance to all patients seen in the emergency room/urgent care areas, and any patient that registers for a non-emergent service is questioned by admissions or nursing staff regarding any concerns they might have about the cost of their Hospital services. The Hospital employs a full-time, dedicated patient benefit specialist who works with uninsured and underinsured patients regarding community care applications and financial assistance. Additionally, a review is conducted of all accounts that become delinquent to ensure that an attempt to contact the patient has been made by Hospital staff. Finally, the Hospital is in the process of adding a community care & financial assistance section to its website. Part VI, Line 4: Tomah Memorial Hospital, Inc. is a 25-bed Critical Access Hospital located in Tomah, Wisconsin. The Hospital's primary service area consists of Tomah, WI, and the outlying communities of Camp Douglas, Warrens, Oakdale, and Wilton. Tomah is located in rural western Wisconsin, and as such a significant portion of the Hospital's patient base is comprised of agricultural workers and members of the Amish community. Additionally, Tomah's proximity to two military installations results in a large portion of services provided to members of the military and their families. The Hospital's payer mix is comprised of approximately 16.4% Medicaid, 33.2% Medicare, 6.5% military, 3.7% self-pay, and 40.2% commercial insurance. The reimbursement challenges associated with providing a high percentage of services to Medicaid/Medicare recipients and the uninsured has required the Hospital to operate at a high level of efficiency, ensuring that all services provided represent an excellent value to area community members. Although the Hospital has benefited from the additional reimbursement afforded through the Critical Access Hospital program, competition for market share with other area healthcare providers requires Hospital leadership to continually reevaluate service offerings and business lines for appropriateness given the healthcare needs of the community. Part VI, Line 5: Tomah Memorial Hospital's Board of Directors is comprised of community members that represent both a cross section of industry expertise (banking, manufacturing, attorneys, physicians, small business, etc.) as well as an appreciation of the healthcare needs of the community. The Hospital generally budgets for a targeted operating margin of between 3% and 5% each year. This target was established by the Hospital's Board of Directors, and is believed to represent an appropriate balance between fulfilling the Hospital's charitable purpose and achieving financial results that allow for continued reinvestment in staff and equipment to remain competitive.The Hospital operates a fully staffed Community Health Initiatives Department dedicated to improving the health of the community through wellness education and preventative healthcare strategies. This Department maintains an active presence in the community, sponsoring such events as an annual Women's Health Night, an annual Senior Health and Safety Expo, and various other educational programs in area schools and businesses. Part VI, Line 7, Reports Filed With States WI X X X X 0 0 0 0 0 0 0 1 0 Joseph Zeps Chief Financial Officer 133841 0 2717 0 11731 0 6231 0 32554 0 187074 0 0 0 Lily Liu MD Geriatric & Family Medicine 300000 0 5000 0 1250 0 7385 0 0 0 313635 0 0 0 Darla Wilson Director of Pharmacy 167396 0 3113 0 2941 0 6994 0 13489 0 193933 0 0 0 Todd Chapman Pharmacist 150212 0 2563 0 5166 0 6309 0 1595 0 165845 0 0 0 Gerald Fushianes PA-C Physician Assistant 145261 0 2815 0 3841 0 6479 0 32545 0 190941 0 0 0 Laura J Miller FNP Nurse Practitioner 128659 0 2438 0 3272 0 5451 0 13459 0 153279 0 0 0 Part I, Line 7 Bonuses are provided based on production and performance. The Board of Directors has authority to determine if a bonus should be granted or denied. Part I, Question 3: Tomah Memorial Hospital does not pay compensation to the Administrator directly. The Administrator is compensated by an unrelated management company, HealthTechS3, and is considered a common law employee of the management company. The Hospital Board of Directors uses the processes described in Part I, Question 3 to help determine appropriate compensation for the Administrator. The Board of Directors also approves the Organization's contract with the Management Company. A Wisconsin Health and Educational Facilities Authority 391337855 2012-08-08 7827337 Refund Revenue Bond Series 2003 issued 7/15/03 0 0 0 A 1767897 7827337 155074 7672263 2012 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 A 1 Cindy Lambert Family member of Chief Financial Officer 41094 Compensation and benefits as an employee 0 Form 990, Part VI, Section A, line 1 The Executive Committee includes the Corporation's officers and Chairmen of Standing Committees. The Executive Committee has power to transact all regular business of the Corporation during the period between the meetings of the Board of Directors subject to any prior limitation imposed by the Articles of Incorporation, these Bylaws, or the Board, and with the understanding that all matters of major importance will be referred to the Board of Directors. The Chairman of the Board presides as Chairman of Executive Committee and the Treasurer presides in the Chairman's absence. Actions of the Executive Committee are subjected to approval or disapproval at the next regular Board of Directors meeting except for those actions taken pursuant to delegation by the Board of Directors. Form 990, Part VI, Section A, line 3 Philip J. Stuart, Administrator of Tomah Memorial Hospital, is employed by HealthTech Management Services, Inc., an unrelated management company. The Administrator has the responsibility of supervising the management, administration and operation of the Organization. Philip was compensated $285,380 for services provided to Tomah Memorial Hospital. Form 990, Part VI, Section B, line 11 A copy of the Form 990 is provided to the Board before it is filed. The Administrator, CFO, and Executive/Finance Committee review the draft in detail. Form 990, Part VI, Section B, line 12c All members of the Board and Administration team are covered by the conflict of interest policy. Potential conflicts are contracts or transactions between the Hospital and a Director or another corporation, firm, association, or entity in which there is a material financial interest. The Hospital administration reviews annual statements for potential conflicts. If the Hospital Administration determines there is a conflict, the person involved must abstain from voting on any matter related to the conflict. Form 990, Part VI, Section B, line 15 The Administrator is employed by HealthTechS3. The Board approves the contract on a three year period with two one-year renewal clauses. Comparability data is used during this process and the decision is documented. The contract was renewed on 6/18/14, with an effective date of 7/1/14. It runs through 6/30/19, and has an opt-out on 6/30/17. The Administrator makes recommendations to the Finance/Executive Committee of the Board for other officers. Comparability data is used during this process and the decisions are documented. This is an annual process and was last completed in fiscal year 2016. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not available to the general public. Financial statements are available through the Organization's bond issuer on the internet, and the Organization presents an annual report to the community, open to the general public, in which a financial report is presented. Additionally, an annual financial report is included in the quarterly mailings the Organization sends to all community members. Form 990, Part IX, line 11g Purchased services: Program service expenses 6,961,244. Management and general expenses 890,330. Fundraising expenses 0. Total expenses 7,851,574. Professional fees: Program service expenses 259,039. Management and general expenses 290,076. Fundraising expenses 0. Total expenses 549,115. Form 990, Part XI, line 9: Net change in fair value of beneficial interest in perpetual trust 54,884. Pederson Trust Fund for the Benefit of Tomah Memorial Hospital 321 Butts Avenue Tomah WI 54660 396173790 Support Tomah Memorial Hospital WI 501(c)(3) Line 11b, II Tomah Memorial Hospital 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0